To do a comment to each post below in APA style with citation, needs 2 credible reference from 2013 and above.
Episodic/Focused SOAP Note
Patient Information: Lily, 20-year-old, Female S. CC: “Sore throat” HPI: The patient is a 20-year-old female who developed a sore throat 3 days ago Location: Throat Onset: 3 days ago Character: sore Associated signs and symptoms: decreased appetite, headache and pain with swallowing Timing: Would ask Exacerbating/ relieving factors: Would ask Severity: Would ask Current Medications: Unknown Allergies: Unknown PMHx: Unknown Soc Hx: Student at the local college. Fam Hx: Unknown ROS: HEENT: Eyes: Ears, nose and throat: Negative for congestion. Positive for runny nose and sore throat, pain with swallowing. GASTROINTESTINAL: Positive for decreased appetite NEUROLOGICAL: Positive for headache O. HEENT: Eyes: Ears, nose and throat: Patient has runny nose, does not sound congested. Patient has slight hoarseness in voice. Diagnostic results: Full vital signs – to include temperature Through mouth and throat exam – specifically looking for puss or enlarged tonsils Rapid influenza test – One study tested 3782 subjects that presented with a fever greater than 38degrees Celsius and either a cough or sore throat. Of these subjects the influenza PCR tested positive 33% of the time and negative 67% of the time. This study showed that the influenza PCR is better at ruling out influenza (Anderson et al., 2018). Monospot test A. Differential Diagnoses Airway Reflux: Acid reflux and sometimes reach higher areas up into the throat. This can create a sore throat and typically leads to a hoarse voice (Adams, 2017). Other symptoms to address include a feeling of a lump in the throat and waking up at night gasping for air (Adams, 2017). Upper Respiratory Infection: Viral upper respiratory infections can create vocal cord inflammation which could be why Lily has a hoarse voice (Dains, Baumann & Scheibel, 2016, p. 9714). Pharyngitis: Bacterial infections can lead to a sore throat and a headache (Dains, Baumann & Scheibel, 2016, p. 9137). Epiglottitis: An infection with H influenza type B, typically presents with sore throat and pain while swallowing (Dains, Baumann & Scheibel, 2016, p. 14434). Mononucleosis: Typically presents with a gradual onset, mild sore throat, malaise and fatigue (Dains, Baumann & Scheibel, 2016, p. 14459). P. References Adams, J. U. (2017). Sore throat and hoarseness might not be just a cold. The Washington Post. Anderson, K. B., Simasathien, S., Watanaveeradej, V., Weg, A. L., Ellison, D. W., Suwanpakdee, D., & Jarman, R. G. (2018). Clinical and laboratory predictors of influenza infection among individuals with influenza-like illness presenting to an urban Thai hospital over a five-year period. Plos ONE, 13(3), 1. doi:10.1371/journal.pone.0193050 Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
Episodic/Focused SOAP Note Template
J, 11, Male, XX (Race)
CC: “Mild ear ache”
HPI: The patient is 11 year old XX male who presented himself with a mild right ear ache, which started two days ago. Associated symptom include possible fever, right ear pain, difficulty hearing from the right ear. Associated symptom are exacerbated with sleep.
Current Medications: Inquire if patient is currently taking any medications, rule out earring loss related to medication toxicity.
Allergies: Inquire about allergies.
PMH: Inquire if patient has a history of acute otitis media or underlying hearing loss. Inquire if patient has had tonsillectomy or an adenoidectomy in the past.
SH: Spends time in pool during summer.
FH: Inquire if family members have history of hearing loss.
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